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Canadian Journal of Anesthesia 50:525-526 (2003)
© Canadian Anesthesiologists' Society, 2003

Correspondence

The laryngeal tube and pharyngeal mucosal pressure

Adrian A. Matioc, MD and George Arndt, MD

Madison, Wisconsin

To the Editor:

We read with interest Brimacombe et al.’s recent article1 addressing laryngeal tube (LT) intracuff pressure, pharyngeal mucosal pressure, and oropharyngeal leak pressure.

The authors confirm in cadavers and volunteers that at recommended intracuff volume (80 mL) and pressure (60–70 cm H2O) the LT #4 generates an appropriate pharyngeal mucosal pressure2 and oropharyngeal leak pressure. Overinflation of the cuffs may be harmful. The symptoms developed by the three volunteers may be indeed produced by the overinflation of the cuffs (140 mL), as required by the study protocol. The manufacturer (VBM Medizintechnik GmbH, Sulz, Germany) recommends a manometer to inflate the LT cuffs to a target pressure3 (FigureGo). Inflation of the cuffs to a predetermined volume is recommended only in situations when a manometer is not available. Reducing the intracuff pressure to a minimum required for a functional pharyngeal and esophageal seal is easier to gauge with a manometer. Also, the LT appears to have less contact of non-cuff portion with the pharyngeal mucosa, thus avoiding high pressure points.



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  		FIGURE Inflation of the laryngeal tube (LT) cuffs using a manometer.

 
The intracuff pressure recommended for the laryngeal mask airway (LMA) in the instruction manual (and clearly marked on the LMA tube!), is ignored in clinical practice. Direct measurement of the LMA intracuff pressure – which correlates with pharyngeal mucosal pressure, oropharyngeal leak,4 and incidence of postoperative pharyngolaryngeal morbidity5 – is missing from the anesthesiologist’s routine. Cuff overinflation is unnoticed because the LMA is used mostly for short cases with spontaneously breathing patients.

As implemented with the LT, the measurement, management, and monitoring of intracuff pressure have to become routine practice with any extraglottic airway device.

References

1 Brimacombe J, Keller C, Roth W, Loeckinger A. Large cuff volumes impede posterior pharyngeal mucosal perfusion with the laryngeal tube airway. Can J Anesth 2002; 49: 1084–7.[Abstract/Free Full Text]

2 Brimacombe J, Keller C, Puhringer F. Pharyngeal mucosal pressure and perfusion: a fiberoptic evaluation of the posterior pharynx in anesthetized adult patients with a modified cuffed oropharyngeal airway. Anesthesiology 1999; 6: 1661–5.

3 Laryngeal Tube Instruction Manual. VBM Medizintechnik GmbH, Sulz, Germany, 2001.

4 Keller C, Brimacombe J. Mucosal pressure and oropharyngeal leak pressure with the ProSeal versus laryngeal mask airway in anesthetized paralysed patients. Br J Anaesth 2000; 85: 262–6.[Abstract/Free Full Text]

5 Brimacombe JR. Problems with the laryngeal mask airway: prevention and management. Int Anesthesiol Clin 1998; 36: 139–54.[Medline]


Related articles in CJA:

REPLY
Joseph Brimacombe and Christian Keller
CJA 2003 50: 526. [Full Text]  




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